Letters to a Third Year Student from the Class of 2021 School of Medicine Letters to a Third-Year Student

LETTERS TO A THIRD YEAR STUDENT FROM THE CLASS OF 2021 SCHOOL OF MEDICINE LETTERS TO A THIRD-YEAR STUDENT

FROM THE CLASS OF 2021 SCHOOL OF MEDICINE

Founding Editor: THERESE JONES, PHD DIRECTOR, ARTS AND HUMANITIES IN HEALTHCARE PROGRAM

Managing Editor: ANJALI DHURANDHAR, MD ASSOCIATE DIRECTOR, ARTS AND HUMANITIES IN HEALTHCARE PROGRAM

COVER ART: ANJALI DHURANDHAR, MD

COVER ART PHOTOGRAPHER: MAX OSBORNE 720-338-3284

FRONT COVER LAYOUT AND DESIGN: HALI JENKINS BACK COVER DESIGN: ANJALI DHURANDHAR, MD

GRAPHIC DESIGN AND LAYOUT: ANJALI DHURANDHAR, MD

APRIL 20, 2021

LETTERS COLLECTED FROM HIDDEN CURRICULUM, FOUNDATIONS OF DOCTORING, THE STUDENT ADVISORS FOR THE ADVISORY COLLEGES, THE GOLD HUMANISM HONOR SOCIETY and THE ARTS AND HUMANITIES IN HEALTHCARE PROGRAM

This publication was made possible by the generous support of the Undergraduate Medical Education Office in the School of Medicine, Arts and Humanities in Healthcare Program Center for Bioethics and Humanities University of Colorado Anschutz Medical Campus

TABLE OF CONTENTS

FOREWORD

AMIRA DEL PINO-JONES MD ...... 1 INTRODUCTION THERESE JONES, PHD ...... 2 FROM THE GOLD HUMANIISM HONOR SOCIETY BRENNA CAMERON, GAVRIEL RODA, YAA ASARE, AMELIA DAVIS ...... 3 LETTERS TO A THIRD-YEAR STUDENT NICHOLAS BIANCHINA ...... 6 CARLEY LITTLE ...... 8 SANJU GARIMELLA ...... 9 ANDREW TANNOUS ...... 11 KAITLYN BRUNWORTH ...... 12 LAURA MCWHIRTER ...... 13 ABIGAIL BRYANT ...... 15 BRENNA CAMERON ...... 16 DAREAN HUNT ...... 17 NATHNA CLARK ...... 18 AMELIA DAVIS ...... 19 SAMUEL DUNHAM ...... 21 JOE FUCHS ...... 22 KASEY PICKARD ...... 23 KIRA GRUSH ...... 24 MATT MINTURN ...... 26 GABRIEL YEPES ...... 27 MICHAEL KLAUSNER ...... 28 ERIN STURMAN ...... 30 CONNOR FLING ...... 31 ANONYMOUS ...... 32 MEGAN BROWN ...... 33 MATTHEW MASUR ...... 35 ANDREW PHAM ...... 36 MEGAN KUNKEL ...... 38 RICHARD SMITH ...... 39 SARA DELENN GRAVES ...... 40 AMANDA THOMPKINS ...... 41 STEFAN PETERSON ...... 43 DYLAN RAKOWSKI ...... 44 ELIA RIEDER ...... 46

AFTERWORD ANJALI DHURANDHAR, MD ...... 49

FOREWORD

I’ve spent the last several weeks looking for the perfect inspirational quotes and excerpts from famous novels to include in this introduction. I’ve considered reflecting on 2020 and the impact of the COVID-19 pandemic but hesitate to include the word “unprecedented” in yet another piece of writing (which I just did…sorry), or handing down the top 10 tips I received from other students and physicians as I made my transition from the 2nd to 3rd year of medical school. I think I want to provide the perfect words of wisdom because writing the forward to Letters to a Third Year Student is such an honor and I don’t want to disappoint. It marks your exciting transition from “medical student” to “student doctor”, and I can assure you that many of the patients you will see will call you “doctor” which at times can feel overwhelming and fraudulent. However, this will be the essence of many of the transitions you will make over time, including student to resident and resident to attending, and it is helpful to embrace those transitions with the same excitement, grace, optimism, and thoughtfulness that I know you all have. You have worked hard and sacrificed in so many different ways. Remember that you deserve to be here and you’re more than ready to continue on this beautiful journey. Needless to say, I still haven’t found the perfect quote or excerpt. I also suspect that many of your fellow medical students and faculty will include very helpful tips and advice for success as a 3rd year in this publication. However, this process and has given me time to reflect on some of my most memorable experiences as a 3rd year medical student, two of which I’d like to briefly share with you. My first patient on Internal Medicine was a young gentleman with advanced AIDS who was hospitalized with P. Jirovecii Pneumonia (PJP). It was the first time I saw PJP and Kaposi’s Sarcoma, and the first time I played cards with a patient (he won by the way). I always felt like I didn’t have enough medical knowledge to be of help, but he was always so excited to see me in the mornings, and I him, and he often gave me encouragement about the path that lay ahead for me in medicine. On OB/Gyn, I stood by my patient’s husband’s side when she developed hemorrhagic shock following a procedure, which later resulted in her having a hysterectomy and a lengthy stay in the surgical ICU. I will never forget the look of fear, sadness, and love in her husband’s eyes, as well as the look of hope and gratitude as she slowly recovered. I envisioned that this is the type of commitment, love, and connection we all seek in our relationships. I feel a little selfish telling these stories as I believe these patients gave me more than I thought I was able to give them at the time. However, I am hopeful that I positively impacted their journeys just as they impacted mine. All of our stories are intertwined. We have the distinct privilege of being a part of our patients’ lives and them a part of ours. Sometimes it is on their best days, and other times it is on their worst day. It is up to you to decide how you will be remembered in their story. As a 3rd year medical student, you have the ability to have a profound effect on your patients, their families, your teams, and your colleagues. Whether you know how to treat PJP, or can promptly recite the differential for shock, to hold someone’s hand, to listen, and to truly be present is going to be more impactful and long-lasting than you will ever imagine.

Amira del Pino-Jones, MD Associate Professor of Medicine Division of Hospital Medicine Assistant Dean for Student Affairs University of Colorado School of Medicine

INTRODUCTION

From 1903 to 1908, Czechoslovakian poet, Rainer Maria Rilke, wrote a series of letters to a young, would-be writer about surviving as a sensitive observer in a harsh world. Rilke wrote about taking risks not only to succeed but also to fail: “Always trust yourself and your own feeling; it if turns out that you were wrong, then the natural growth of your inner life will eventually guide you to other insights." He wrote about being impatient to know everything but being comfortable with knowing nothing: "Try to love the questions themselves as if they were locked rooms or books written in a very foreign language." And he wrote about being aware of yourself in the world but being cautious about taking yourself too seriously: "Don't be too quick to draw conclusions from what happens to you: simply let it happen." That book, Letters to a Young Poet, has inspired many subsequent writers and teachers to share their own observations and insights, their own words of wisdom and warning, with other young readers embarking on a life in the arts, in religious and public service, or in the professions of law and medicine. These individual works are now part of a series called The Art of Mentoring and include such titles as Letters to a Young Jazz Musician by Wynton Marsalis, Letters to a Young Conservative by Dinesh D'Souza, Letters to a Young Contrarian by the late Christopher Hitchens, and Letters to a Young Lawyer by Alan Dershowitz. The first collection of Letters to a Young Doctor was in 1996 by surgeon and writer Richard Selzer and meant to be, in his own words, "pedagogical and comradely--a reaching out to share." The goal of the second, Perri Klass' 2007 volume, Treatment Kind and Fair, was "a combination of maternal and medical wisdom." Her letters are addressed to her son in medical school--the very child born during her own education at Harvard in the 1980s, where she was one of only four women in her medical school class. Writing about and across their respective lifetimes, both Selzer and Klass not only reveal the compelling mysteries of the world of medicine but also represent the tedious challenges of the job of medicine. Members of the Class of 2021 are now part of this long and respected literary tradition by giving you practical advice, helpful suggestions, and personal reflections on the year ahead of you in this collection, Letters to a Third-Year Student. Since I launched this project a number of years ago, I, like all of the readers of all of such letters, have been given the opportunity to learn along with you, to marvel at your courage and creativity, to applaud your stamina and resourcefulness, and to bear witness to your pain and your joy. Just as these letters provide a mirror of your own experiences and emotions in the third year, they also provide a window for those of us looking in at you and looking out for you as you make this journey, so please share them with your partners, your family members, your friends and your teachers. I will close, appropriately enough, with another passage from one of Rilke's letters in which he encourages that very first reader to experience and express all that is happening around him, to him, and because of him: "Turn to what your everyday life affords; depict your sorrows and desires, your passing thoughts and beliefs in some kind of beauty. Depict all that with heartfelt, quiet, humble sincerity." If you follow such advice, just imagine what letters you yourselves will write . . .same time, next year. I can't wait to read them!

Therese (Tess) Jones, PhD Arts and Humanities in Healthcare Program Center for Bioethics and Humanities

FOREWORD FROM THE GOLD HUMANISM HONORY SOCIETY

Dear Third-Year Colleagues,

As you prepare to enter into your clinical rotations, you stand at the beginning of what will be a period of immense growth. Right now, you are bursting with knowledge. You know the mechanisms of action of more drugs than you can count. You know the exact electrical currents that allow the heart to pump, and you know a bunch of rare kidney diseases and even more rare metabolic disorders. When you start rotations, you will all at once feel that you know so much yet nothing at all. That’s okay. You’re here to learn. Good physicians are knowledgeable and prepared. They are great scientists. But great physicians are more than their medical knowledge. They are human beings, first and foremost.

Great physicians show up for their patients. Rather than shying away from the emotional toll of their patients’ stories, they embrace them. Throughout this year, you will hear and carry with you so many stories: the stories of your patients and their families; the stories of your residents, attendings, and fellow med students. They will intertwine with your own story of why you decided to become a physician, and if you allow it, these will continue to mold you into a great doctor.

Each of us -- Brenna, Gavi, Yaa, and Amelia -- wants to share one patient story, out of the many that are now intertwined with our own. Each of these stories reminds us of our common humanity in medicine. They give us strength as we continue our training and remind us of how we can make a difference in a patient’s life, not just through medications and surgeries, but more importantly, through our care and the art of medicine.

Brenna: I had a patient on my internal medicine team who scared me half to death. He was dying, to put it frankly, and that scared me. His children came from all corners of the country to be by his bedside. They were my age. Young and ambitious and just beginning to jumpstart their lives when they were all forced to stop, unsettled by their father’s drinking that was now threatening his life. They were fierce advocates for their father and as such, often did not see eye to eye with many of our team members. My sister had just recently been hospitalized with health concerns that were still a mystery to us at the time but were all the more frightening because of their uncertainty. I understood all too well what this family was going through. And rather than become frustrated with their anger, I leaned into it. I validated their concerns and frustrations. I showed up every morning ready to give them my patience and empathy and because of that, they trusted me and began to trust the rest of the care team.

Gavi: He was a young man, previously healthy. Over the month preceding his hospitalization, he had felt increasingly short of breath while playing golf, his favorite way to spend free time. Now, he had heart failure secondary to a non-ischemic cardiomyopathy. He had no family history and no known risk factors. This was a devastating blow to his life- one that was inexplicable to him and the medical team alike. Each day, after I listened to his irregularly beating heart, I would remove my stethoscope and hand it to him so he could hear the difference over time. As we titrated his medications and removed excess water from his body, we rejoiced in his physical, albeit superficial, return to normalcy. Despite improving medically, we talked about the things medicine cannot heal: the toll of his new condition, the anxiety he felt about its course, his fear of death. On our patient’s last day prior to his discharge home, he handed me a note written on the back of his new cardiologist’s card:

“keep me in mind.” I was stunned. Here stood a man with open arms, expressing gratitude, despite facing incredible uncertainty and fear. He reminded me of what was most important when my uncle was transported to hospice after a long battle with multiple myeloma- it wasn’t explaining the next steps or the lab trends. It was leaning into the pain together. Both this patient and my uncle remind me that medicine alone offers only one piece of the healing process. Compassion and our presence provide something knowledge and clinical practice cannot mend.

Yaa: He was an 88-year-old veteran who came to us with profound fatigue after dialysis. When I walked into his room, my first thought was that he reminded me of my grandfather: the pattern of his wrinkles, the studious eyes, the cane resting near the bed. His chest X-ray showed pneumonia, so we began to treat him with antibiotics. Day after day, we greeted each other the same way. I would say “Good morning, Mr. J,” and he’d say, “It’s a blessing to be alive, Dr. Yaya.” He would tell me how his night was, and I would perform a physical exam. At the end of each visit, I would find him a heated blanket and tuck him back into his bed or the chair. Then he developed symptoms of delirium. At 6pm one evening, I was on my way out the hospital doors when I got a call that he was angry and refusing all assistance. It was only right to pay him a visit. By the time I arrived, he was calm and lying in bed. I greeted him and he responded, “You came to see me.” There was nothing else to say but, “Of course, sir.” I sat on his bed and held his hand until he fell asleep. After several similar episodes, there was a family meeting regarding goals of care. I met his wife, Mrs. V, who was adamant that we could “give him back his health.” Despite multiple interventions, he remained delirious and ill on most days. She pulled me aside one day and said, “We don’t know each other well, but something tells me your spirit is what my husband needs. All I ask is that you make him laugh at least once a day. That’s good enough.” I tried my best to fulfill this request until my rotation came to an end. Several weeks later, I received a phone call that he had passed away. I still don’t quite know the “spirit” Mrs. V was referring to, but I’m forever grateful that she felt it had healing power, however temporary. While I learned endless treatment algorithms during rotations in 3rd year, what I remember the most is that sometimes, it’s as simple as holding hands and laughing together.

Amelia: “What is going on? What does this mean?” His bed was at the far end of the room with the window shades open to let in the sunlight. He lay grumpily in his bed, insisting, “I feel fine. When can I go home?” His daughter, her worried face drawn tight, shook her head at her father’s words and turned to me, inquiring again, “What is going on? What does this mean?” The pulmonologist and the fellow had just whisked themselves away from the bedside after a whirlwind of percussion, palpation, and auscultation. The pulmonologist asked me a rapid-fire series of questions about what I thought was going on based on what I heard and saw. Words like “effusion” and “malignancy” and “multiple myeloma” floated around the room as uncertain possibilities. “We need a tap,” the pulmonologist declared before placing his hand on the father’s shoulder and nodding a farewell. Standing there alone with the daughter’s questions, I felt the heavy weight of responsibility. I took a breath to shoo away the brief moment of panic that imposter syndrome bestows upon me from time to time. I didn’t have the fancy answers and all that I didn’t know I answered honestly. But I could share what I did understand and what the medical team was doing. I could sit with her and her father for as long as they needed. I could learn of his lifetime of good health in several countries and the names of the members of his large and affectionate family who was eagerly awaiting the homecoming of their patriarch. I could take the daughter’s cell phone and listen to her exuberant and concerned sister-in-law as we navigated her questions together. I could

openly validate the fear and frustration that can accompany an unexpected hospital stay. In that moment, amidst all the uncertainty, I was exactly where I needed to be.

These are only a fraction of the stories we have collected. If we could impart any advice to you, it would be to make sure that during this busy year, you take time to collect your own stories. You all are entering your clinical medicine careers during an unprecedented time. While this cannot be ignored, it makes it all the more important to separate your patient from the disease, to see the human before the pathology. As a third-year medical student, you have the gift of time. Choose to spend it with your patients when you can. Humanity and the joy of becoming a physician reside within these connections.

Brenna, Gavi, Yaa, and Amelia On Behalf of The Gold Humanism Honors Society (GHHS)

Dear Amazing Future Physician, Welcome to third year! I cannot wait for you to embark on this amazing journey and hope you get to explore all the aspects of medicine that drew you into this rewarding career. I’m not gonna lie to you… third year is difficult, and I won’t pepper you with illusions that you won’t at times question whether you are good enough to be here. As third year progressed, I found myself returning to the following questions to provide myself some clarity, and I hope it can do the same for you. 1. Have you eaten today?

Let me tell you about getting hangry and my new terms: hustrated (hungry + frustrated) and had (hungry + sad) are very real. When you are feeling despondent by all the events of third year, grab a granola bar and see if things change. Even a pack of peanut butter M&Ms made many night shifts worth it.

2. When is the last time you talked to a fellow med student?

Being a medical student is an extremely unique experience, especially during your third year. In fact, even as a fourth year, I can feel myself slipping in my ability to relate to the confusion, frustration and awe of the clerkship time. When in doubt, talk it out. Lean on your fellow med students as you will be surprised you aren’t the only one feeling what you are feeling. Yes, everyone has gotten to the end of presenting labs and realized they were sharing the wrong patients’ labs. You are not alone. 3. Who did you help today?

As a third-year student, you will often ask yourself, “Will anyone even notice if I wasn’t here?” Sometimes, you will feel like you are, as a fellow classmate put it, “paying for the privilege of being in the room.” Yet, you made an impact on someone, I promise. Did you spend an extra 5 minutes talking to a patient about their family? Go and grab the surgical patient a cup of water? Hold a nervous child’s attention while the pediatrician talked the parents? Or give verbal support to a woman in labor? You did something for someone. While it may seem small, it may make someone’s day 1% better, and that is worth it. 4. Seriously, have you eaten and had something to drink?

5. The final piece is not a question but a task. Go back to your medical school personal statement. In it, you will find something: passion. A passion to help people, learn about medicine, treat and cure disease. You all have written about wanting to change the healthcare system, understand the patient’s experience and help the underserved. Remember why you went into medicine in the first place. Often you will find yourself grounded in your purpose, and the long days and stress of clinical grades will become waves in the background.

And after all this, I return to the all-time favorite piece of advice that I have gotten in medical school: No one thinks about you as much as you think about you. Remember when you

dropped the sterile instrument in the field? Turns out the surgeon will forget within the next 24 hours. You know how you didn’t know the differential diagnosis for left upper quadrant abdominal pain? You give upwards of 150 presentations throughout your internal medicine and primary care rotations. Trust me, no one remembers each one. Give yourself grace therefore to make mistakes, try new things and above all, become a better doctor. I promise you will end third year reminded of why you are here, and the amazing days are more at the forefront of your mind than the bad.

And don’t forget to eat!

Nicholas Bianchina MD Class of 2021

Dear Third-Year Student, This next year of your life will be filled with excitement, frustration, gratitude, confusion, self- doubt, love, curiosity, anxiety, passion, and joy. It will push you to your limits while you simultaneously experience the highest of highs.

When I reflect on one of my most memorable moments of third year, I am brought back to a patient’s room on the 9th floor at Denver Health. This was someone I had the pleasure of taking care of for two weeks straight. We had vulnerable conversations about her struggles with diabetes and subsequent end-stage renal disease. She told me about her dog giving birth to 6 puppies on a pile of dirty laundry. She would always encourage me while I presented her case in front of the team on morning rounds. She even participated in rounds and always made our team laugh. At the end of those weeks, it came time for the team to pass the baton to the new attending and residents. When we told the patient, she was visibly upset. We had worked as a team on her care and really bonded over discussions about her life and what she had been through. As she was tearing up about us leaving, she said, “well, are you at least going to sing me something?” Without skipping a beat, my attending put his hands on our shoulders and shouted, “You are my sunshine, my only sunshine. You make me happy when skies are gray. You’ll never know dear how much I love you. Please don’t take my sunshine away!” We all joined in at various points and watched her face light up. It was an instance of pure, untainted joy.

Keep any eye out for moments like these; they will sustain you.

Carley Little

Dear Phase III Student, Do you remember your first day of high school? First day of college? What about your first day of medical school? Do you remember the mixed feelings of excitement and the nerves that came with it? I’m sure that many of you feel similarly now as you enter the first day of the rest of your lives, and I hope you remember that YOU ARE READY! But, just for good measure, below is a list of things to pack into your backpack/purse/messenger bag on your first day in clinic:

Pens, pencils, and a notebook This year, you will be taking a lot of notes. And unlike ever before, these notes will come as quick wisdom pearls from your attendings, residents, classmates, and patients. Whether you need to write down the Parkland formula for the 40th time, calculate an anion gap, jot down a room number, or even take note of the Italian restaurant your patient recommends, quick access for notes is key! A few granola bars, goldfish, or other quick snacks 90% of the time, you will get a lunch break, and if you’re in the hospital will be surrounded by more crackers and peanut butter than you could’ve ever imagined. But the other 10% of the time (whether you’re scrubbed in on the longest case ever, your residents seem to have forgotten to eat so you follow suit, or your EM preceptor is snacking on chocolate covered almonds, and you are stuck longingly staring), these snacks will be there to save the day. I’m almost positive I will always have goldfish powder stuck in the crevices of the inside pocket of my white coat, but I wouldn’t have it any other way. Water Stay hydrated! This isn’t the first time you’ve heard this. You will be moving all day and talking more than ever before; so, trust me, you will need the water. (Also, it wouldn’t hurt to scope out the staff bathrooms in clinic or the hospital sooner rather than later.) White Coat So exciting! If you precepted in a location that didn’t require a white coat during your first two years, this is the first time that you not only can wear your white coat but are sometimes required to! This short coat is a rite of passage, and when you’re on the wards with it on, it’s a truly unique feeling! Also, the pockets in this thing are ridiculous (in a good way)- use them! Stethoscope I forgot it on my first day of pediatrics. Don’t do that. But if you do, that’s okay, too. Cell phone (and maybe an extra charger) Definitely not for texting (unless you’re texting a preceptor). But it is the handiest device filled with so many useful apps! My favorites include: UpToDate, DynaMedPlus, MD Calc, Epocrates, Sanford Antimicrobial Guide, and of course, you will need the Duo Mobile app to access Epic. Laptop For all the notes you get to write! Some places have a designated medical student laptop; some don’t. Take it with you on day one just in case! Your brain No, this isn’t a request for you to know everything about the specialty on day one. Rather, be prepared to learn. The best way to do that is to review concepts every night, including the night before your first day. Things like a normal physical exam, common diagnoses, and of course, some antibiotics are always helpful to know! Be prepped,

learn lots, and apply what you learn to patients or discuss it with your team. One of the best parts about third year is seeing everything you’ve been learning about thus far! A smile J Last, but quite possibly the most important, bring a smile and a good attitude. This isn’t limited to the first day but every single day. Even if you feel like you know nothing, are hungry, forgot your stethoscope or anything else, as long as you have a positive attitude, every single person around you will be more than willing to help you out! Some days will be hard, and some will be the greatest, but keep your spirit high and enjoy the year ahead!

I hope this checklist helps a teeny bit! You can and will do this amazingly! Have so much fun and please feel free to reach out!

Warmly,

Sanju Garimella GHHS (c) 720-320-1164

Shoot your shot

Dear Phase III Student,

I would like to open this letter by sharing a personal anecdote during my third year.

It was time to round on our patients during surgery. I had arrived around 4AM to complete the list. I had spent a nice chunk of my precious time deciding if I wanted to add a more integrative touch to the assessment and plan for my patient’s persistent hypotension, in addition to the run of the mill care we have previously provided. A very miniscule thing, but I can add my own spin to the patient’s care. Sounds simple: let’s give them an IV bolus of saline.

But was it that simple? What if I am wrong? What would the other members of the team think of me if I am wrong? Chaos ensued.

The majority of this fear derived from my chief resident. At the time, he was everything I wanted to be. He was stern, brilliant, and knew exactly what he wanted from his team. He would own his patient during rounds and the operating room. He would reasonably express disappointment and anger when members of the team fell short of his expectations- because, as he emphasized, these were our patients. All things considered I was nervous about letting my role model down.

Forget it, I will go for it. I have proven my worth up to this point. I can do it.

During rounds, I announce my plan and my chief shakes his head left to right. There was a grin on his face. I had let the guy down. However, he makes a brief announcement to the entire team. He states that he is proud of my overall attempt, stressing the importance of owning your education, making mistakes along the way, and learning from those experiences.

To the rising third years, my advice is short and sweet: shoot your shot. Own your patient. Make mistakes. Build your confidence. Find your role model. Become your role model.

Sincerely,

Andrew Tannous

“I can accept failure but I can’t accept not trying.” Michael Jordan

Dear Third-Year Medical Student, On the first day of my first ever clinical rotation, the attending gathered our group of medical students and sat us down in a small meeting room to discuss expectations. “Welcome to our hospital!” he began enthusiastically. “We have only two rules here. Number one: Be humble…” He then paused thoughtfully, deciding on how to best articulate the second rule. “And number two: Don’t be an asshole.” When thinking about giving advice to a third year, the only thing I would add to the “be humble, don’t be an asshole” adage would be this: Be brave.

“Be brave” can mean many different things in third year. Sometimes, “be brave” means that you must look a patient square in the eye and ask them if they ever feel like they want to kill themselves. “Be brave” can mean that you pull a slippery new baby from its mother’s belly and deliver it into her arms with your attending hissing in your ear, “SIMBA GRIP, Kaitlyn, hold on TIGHT!” “Be brave” can mean asking some of the most bizarre questions: “Tell me more about the color of the fluid that leaked from your vagina.” “When you witnessed God emerge from the mountain, did you actually hear him, or was it more of a physical sensation?” “When was the last time you had sex?” “Did your poop seem fatty and float to the top of the toilet?” On the more difficult days, “Be brave” can mean sitting in silence with a patient after you’ve just told them that they have cancer.

Other times during the third year, “be brave” is a lot less glorious. Some days, “be brave” means bumbling around an entire hospital before finding the doc box. It means looking your new attending in the eye and shaking hands even though you are terrified. On night shifts, “be brave” can mean doing everything in your power to avoid nodding off in your chair at 4am. In the OR, it can mean speaking up when you accidentally broke scrub. On many days, it takes every ounce of bravery you’ve got just to pull yourself out of bed in the morning and show up. “Be brave” can mean accepting that you will take a lower grade on this rotation because a family event takes precedence over studying. There will be days when a patient’s story is so tragic that it absolutely destroys you. On these days, “be brave” may mean allowing yourself to cry. And if you find yourself crying in the parking garage, “be brave” means pulling it together before you put the car in gear.

Be brave, third year medical student! You are more resilient than you know.

Kaitlyn Brunworth

Dear Phase III Student, You are poised on the brink of entering the clinical phase of medical school. If you are anything like me, you may be experiencing a patchwork of emotions: fear, excitement, anxiety, doubt, happiness, eagerness, anticipation, dread. As the year progresses, more emotions will join. Feelings of stupidity, helplessness, frustration, and exhaustion may join. But so will many moments of joy, satisfaction, pride, and wonder.

For me, third year has been almost like a long trip to a destination where you have never been.

As you start out, you pack your belongings carefully, arming yourself with what you will need for any possible scenario you may encounter. You overthink about what clothes to bring. Business casual and white coat, or scrubs and Dansko clogs? ID badge on a lanyard around your neck, or clipped to your pocket? You obtain maps to plan and chart your way. Now, where can I find the scrub machines again? As you head off, you may encounter some setbacks. Long wait times at the airport security may hold you up (HELLO, VA badging office). There may even be some delays along the way. But finally, your feet leave the ground and you know that your adventure is beginning.

You know that when you complete your trip you will have had a multitude of experiences. You will be exposed to a variety of new and exciting cultures, some of which may be completely foreign to you. You will meet people from all walks of life. From patients with completely different backgrounds and life stories than your own to ones that you automatically connect and identify with. From the sarcastic resident to the austere attending to the lovable intern, you will learn not only about what specialty you connect with but also about the kind of doctor you want to model and become.

You will climb to the summit of peaks, but there will certainly be some valleys you will have to cross as well, sometimes perhaps even in the same day. For me, this occurred over and over again. Going between being completed drained and sleep-deprived after coming in at 4 am for another exhausting day in the OR to flying across states in a private plane in order to help harvest and hold a human heart in my hands, and feeling the warm California breeze at 2 am before returning for another busy day of surgery.

There will continue to be the annoyances of traveling, booking flights and accommodations, figuring out transportation, and navigating unknown areas. For me, these annoyances in third year came in the form of mandatory direct observation forms, presentations, and assignments. Necessary, but often something that I felt took me away from feeling as “in the moment” as I desired.

But at the end of it all, you will have returned. You might be a slightly different person than you were when you left for your trip. The experiences you will have had will remain with you and live on as memories for a lifetime to come. You will relish the memories of your triumphs and successes, and the bad/embarrassing/frustrating moments will fade, and perhaps even turn into amusing anecdotes to tell your friends.

So, if I could give one piece of advice, it would be this: the trip you are embarking on is full of the unknown. As much as you plan and prepare for it, you may be surprised by what you find when you get there. But if you can go into it with an open mind and heart, your world

will be opened to something new. So be enthusiastic, open to new things, and just be willing to take the first step. Safe travels.

Laura McWhirter

Dear Third-Year Medical Student, I think the best advice I got in third year was from an acting intern who told me, “Put a smile on your face even if there isn’t one in your heart.” This is a bit cynical but is really good advice. And luckily, most of the time that smile won’t be fake because third year can really be a lot of fun.

It seems like just yesterday that I was in your shoes, about to start 3rd year and all of the joy and challenges that come with it. I’ll tell you that at that point in time, I was equal parts excited and terrified. I couldn’t wait to interact with patients every day but was scared of not knowing enough, breaking sterile field, and being yelled at by my attendings.

If this is how you feel right now, you are not alone. And be assured, things will go wrong. You will not know every answer on rounds, you will probably mess something up, and there is a possibility someone will become mad at you. Thankfully, your supervisors are also human and remember being new to medicine too. Almost every person I met during 3rd year was extraordinarily kind, understood my current level of education, and was very enthusiastic about helping me learn.

I think the best example of this for me was during my MSK rotation. I was scrubbed in with two attendings who were breezing through a spinal fusion. At one point they very kindly offered to let me use the mallet and pound in a piece of hardware. I wound up, and came smashing down, not on the metal driver, but right on my attending’s hand.

Great success.

Thankfully, he wasn’t hurt, and both of the attendings laughed it off. They mocked me endlessly for the rest of the rotation but ended up letting me do part of the surgery when one of them had to step out, and it became one of the most meaningful medical experiences I have ever had.

This is not to say that hitting your attending is a good idea- if it had been any other situation, I could easily have been kicked out of the OR. But know that these people recognize that you are learning. If you show enthusiasm and ask them questions, they will be excited about showing you what they are doing. You don’t have to know every answer; the reason we are here is because we are still learning. But you do have to show that you are happy to be there and eager to be involved in your education.

So, don’t forget that smile. It will show people you care.

Good luck this year! You’ve got this!

Abigail Bryant

Dear Third Year, Buckle your seatbelts. This going to be one hell of a ride.

Going into third year felt like turning a switch. I went from studying long hours in the library, only talking to three or four of my classmates to talking with actual patients. I went from my head in a book, memorizing drug mechanisms of action to learning how we actually use those drugs in clinic. It’s a jolt. You’ve just spent months studying for Step—congrats by the way—and at once, you will know so much and yet so little. Third year is so radically different from your first two years that most days it felt like I had started at a new program. And let me tell you, that program was so much better than the first two years. None of us went to medical school so that we could spend long hours in a library for the rest of our lives, learning pathophysiology. You went to medical school to take care of patients. And finally, you have arrived. Starting now you will be taking care of patients. Every day.

Third year is so many things. It’s fun. It’s challenging. It’s exhausting. You’ll have experiences you’ve never had before. You’ll talk with patients and learn their stories, many of which will stay with you for the remainder of the year. You’ll see more sunrises than you care to count, your day starting long before the sun is up. And if you’re anything like me, you’ll nap more than you ever have before.

Third year is like having a new job every two weeks to a month. You show up on your first day having no idea what the expectations are, where the bathroom is, when (if ever) you’ll be able to have lunch (or leave for the day). By the end of the year, these things no longer bother you. You’ve figured out how to learn them as you go. What’s a little harder is the feeling that you are the person on the team that knows nothing. You are completely lost during rounds for the first week, spending twenty minutes trying to figure out a plan for your patient only for your team to smile after your presentation, nod and say: “Nah. We’re going to do something else.”

It’s okay though. First and foremost, this is a year of learning. You are supposed to get things wrong. And I’ll let you in on a little secret: the expectations for third year students are SO low. It was the thing that surprised me the most about third year. It doesn’t mean that the year is easy or that you can slack. You can’t. But your teams will be happy that you showed up on time, that you are willing to see patients, that you even just attempt to give a plan, and that you ask questions.

Ask all the questions. Seriously. Nothing is off limits. I asked anything from what a chest tube was to how to treat acute pancreatitis to what the heck a T2 hyperintensity meant. I even asked about nasal cannulas, what heated high flow was and when to switch a patient to it. Ask how to talk to patients, how to give them bad news and good news, how to explain what’s going on with their bodies.

So, hold on tight. Breathe. Learn. And enjoy. You’ll be amazed with how far you’ve come at the end of this year.

All the best,

Brenna Cameron GHHS

Dear MS3, Welcome to the year that you have been waiting for. The year that you get to dress up and play doctor. I say play because most of the time, you will feel that way. Imposter syndrome follows a bell curve that peaks in third year, and I hear one can experience Imposter Syndrome exacerbations even as an attending. There are a few pearls I’ve learned over the last year that I’d like to share with you:

1.) I like to describe third year as basically starting your first day of junior high every other month.

“I don’t know where I’m going.” “I don’t know where the bathroom is.” “Gosh, I hope I make friends.” Don’t’ worry though if you don’t find your people during that month; you’re switching schools in a month anyways. 2.) Please, whatever you do, eat each morning on surgery. Even if you feel nauseous, or don’t think you have time, eat something. It is incredibly embarrassing to almost pass out in the OR. And if you do pass out, that’s okay, too. You can still be surgeon someday.

3.) When residents and attendings ask you what field of medicine you are interested in going into, you have two ways of answering this:

a. You can be genuine and say what you’re interested in and risk that you may receive less teaching if the said clerkship is not what you’re interested in going into. b. You can lie and say that, “You’re not sure, but what you’re doing now is very interesting,” as you help with a bowel cleanout.

I recommend option “a” because maintaining your integrity throughout third year is always more important than earning brownie points. 4.) For those who tell you that you won’t have a life during 3rd year, don’t listen to them. 3rd year is tough, and some rotations have ridiculous hours. 3rd year forces you to discover your priorities. You may be surprised how these change as the year progresses.

5.) You are not in medical school to perform or impress anyone. Trust me, you are already impressive!!! Instead, you are here in this privileged position to learn and grow into the doctor you were called to be. When you feel the weight of “performing” as you slip on that white coat and lay the stethoscope around your neck, remember that you are here to learn, serve, and advocate for your patients. Let that be enough to impress anyone, especially you.

Darean Hunt

Dear 3rd Year Student, When I was a 1st and 2nd year student, talking to 4th year students was incredible. They were absolutely brilliant. There was no way I could ever know as much or be as smart as they were. As it turns out, all I needed to do to become that kind of 4th year was to… drum roll, please… complete my 3rd year. My friend, I promise that this will happen to you too. 3rd year rotations are an incredible experience designed to teach us the real life, rubber-meets-the road skills we need to become doctors. You have the opportunity to practice, mess up, and improve in an environment where you aren’t going to hurt anyone. This year is going to be full of surreal experiences that only a small portion of the population has the privilege of being present for. It is full of excitement and is marked by a sense of fulfillment as you take a real part in affecting the lives of your patients for the better. This year is also full of frustration, apprehension, and bodily fluid. With that, I’d like to share with you some things I wish I had known before starting this incredible journey.

• Work hard. If you can, work smart so it looks like you’re working even harder than you were before. • Ask your residents questions before rounds. It’s better than being pimped by an attending during rounds while unprepared. • Practice calling consults early in the year so you can call all the consults for your patients later in the year.

Things will happen during your 3rd year that will make you question yourself, your beliefs, and your choices. There is no perfect 3rd year experience, but the imperfection is what will mold you into remarkable doctors; it will mold you into a remarkable person. It tests our resolve and our determination to be the best we can be. One trying experience I had was during my surgery clerkship. If you haven’t heard yet, the hours are long, and you don’t have many hours to do much other than be at the hospital. Two weeks into the rotation, my third child was born. I got two days off to attend my daughter’s birth and help my wife home from the hospital. My 2- and 3-year-old daughters did what they could to help with the newborn, but we all ended up exhausted and a little burnt out. This was difficult, not only for me, but for my family too. But we did it. And along the way I got to help remove tumors, prolong life, and even cure people. I got to see the look on the faces of veterans whose quality of life had improved for the first time in years – and it gave me the courage to pursue this career path. These are experiences and feelings I will always remember. They are experiences that have changed me for the better. You will have those sorts of experiences, too. Not exactly like mine, but perfectly yours. Through it all, you will gain knowledge, power, and because of your experience, wisdom. Your 3rd year will be imperfect and challenging, and you will definitely lose some sleep. It will be a defining year in your medical career as you get a glimpse into various fields to learn which specialties you love and which ones you certainly will never pursue. Though I am excited to move on in my career, I still envy just a little bit the opportunity to spread your wings for the first time. Good luck! This year will be a wonderful, fulfilling whirlwind.

Nathan Clark

Dear Future Physician at the start of your Third Year, Passion and perseverance. These intangible qualities, extolled by Angela Duckworth as the recipe for grit, likely informed your journey to medicine. Do you remember when you knew you wanted to be a physician? Was it a moment? Was it a realization that came to fruition with the accumulation of years and experiences? Somewhere along the way, you found something that drew you to this field: an igniting passion. During your journey within medicine, perhaps you encountered the unexpected, and perseverance guided you. On the brink of your third year, I hope that passion and perseverance will continue to accompany you on this formative year of becoming a physician, just as they did for me.

For me, third year was an opportunity to affirm my passion for medicine and the stories we encounter in this profession. The first two years of preclinical work seemed like a flurry of multiple-choice exams and library studying, and it was a struggle for me. It all faded very quickly into the past when third year clinical rotations started. Spending time with my patients before, during, and after rounds and presentations were a definite highlight of my year, and I was humbled again and again by the intricacies of human lives. My passion for combating inequity and injustice found itself rooted in speaking up when it mattered. I was reminded of why I chose to go into medicine. Humanity intersected with medicine, and I became reinvigorated by spending time with patients, peers, and mentors.

Though third year gave me ample opportunity to delve deeper into my passions, I found myself in the midst of a year of perseverance. I was reminded, again and again, that things will not always happen as we expect, whether with a patient outcome or an exam or the path of our lives. I cried in bathrooms alone. I cried in my mentor’s office and in patients’ rooms. The pervasive feeling that I was “not good enough” to be here never quite fully dissipated. Internalizing the constant stream of feedback that I received throughout the year in the pursuit of perfection stole a little of my joy.

I found it helpful to write down three good things that happened each day. It ranged from the seemingly inconsequential to the monumental: eliciting a smile from an elderly gentleman labeled as “grumpy” when asking about his rock band days, sitting with a teenager who opened up about gender identity, successfully checking a child’s ears and reassuring the worried parent, thriving in managing a patient visit from beginning to end (with supervision, of course), spending a day outside in freshly fallen snow, recognizing that I needed to say, “no” when my plate was full. Somewhere along the way, I became more forgiving of myself. I held my people close this year and found connection in sharing my own stories and experiences with my classmates and my family. Though it didn’t always go smoothly, I cried, laughed, and tried to ride the waves as they came.

In this highly transformative year of your medical education, I hope you’ll catch a deeper glimpse into the complex depths of humanity and further appreciate just how privileged we are to spend our entire careers being immersed in the joys, the sorrows, the mundane, and the exhilarating in all that humanity offers.

If I could tell my past self anything at the start of third year, it would be to grant myself permission: permission to feel belonging in this profession, permission to release my unrealistic aspirations of perfection, and permission to sink fully into the emotions that third year may bring and to be as present as possible. Third year is a process of becoming, which asks for passion, perseverance, and patience with ourselves.

No matter how you feel at this moment as you embark upon your third-year journey, you can do this. You belong here. Medicine so needs the strengths and gifts that you bring to our world.

Wishing you all the best,

Amelia Davis GHHS

Dear Phase III Student, For me, the one thing I wish I had been told more often and taken to heart was how fast third year goes. I remember my first day of third year. I was on nights at Children’s. All I could do was sit there sweating from nerves as my team received sign out because I had no clue what was going on. Since then, my rotations have all flown by in what feels like the blink of an eye.

Hopefully, you do not have the same sweaty experience, but if you do, remember that you are not the first and will not be the last. For those of you reading this, I want you to take away two main points. First, there will be bad times during your year, but that these are short and temporary and will eventually pass. Second, that the good times will fly by, so take advantage of them while you can.

When looking back at what I consider the bad times, I mainly think of the very sick patients, some of whom did not survive. I remember the emotions of my team as they came to this realization. I remember the looks of the family members. These are the hard times. These are the moments when you will be tested, but like everything else, these too will pass. And in these darker moments, try to remember that you are stronger than you know and will make it to the other side; after all, this is what you have been waiting your whole life to do.

One aspect that you may be worried about, that is not actually that bad, are the occasional times when you look dumb or don’t know what is going on. You will make a mistake. You will not know many questions. You might even have an occasional team member who will keep asking questions until a question is found that you cannot answer. I do not feel antagonized by these moments because when I look back to one year ago, the skills I have developed in third year greatly exceeded my expectations that I cannot help but to be pleased with the person I have become.

If you are thinking that you will be the same person one year from now, I wish you all the luck in the world. However, I doubt that you will be, nor that you really want to be. You want to be better. You want to be stronger. You are about to embark on what some might call the best time you never want to have again. I know that sentiment is true for me. If someone asked me to repeat third year, I would definitely say no. But I would be remiss to not look back and admire how third year shaped me and my life goals.

I will forever be grateful to the residents, attendings, and especially, the patients who all allowed me to practice my craft and build the foundation for the rest of my medical career. I will take with me their stories, I will take their emotions, and most importantly, remember the emotions during all of this. All with the hope that I can build upon this amazing foundation and truly become the physician I wanted to be when I put on the short white coat.

Good luck, and don’t forget to enjoy the small things. If it makes you happy, chase it.

Samuel Dunham

Dear Phase III Student, Welcome to the world of clinical medicine! While you still have thousands of multiple choice questions to keep you company the next couple of years, you have reached the point when the “78 year old female who presents to clinic with nasal discharge,” is a human being who requires more care than deciding between letters A-D. With this, my advice to you is simple: be your patient’s person.

My first day of hospital medicine, I was asked to obtain a history from a patient in her eighties who presented with acute shortness of breath. She noticed the discomfort during her weekly hike. What jumped out to me was how she defined healthy living: she ate from her garden, took daily walks with her dog, and avoided alcohol and tobacco. It was the first time she had ever been in the hospital and, accordingly, she was scared. I noticed a novel on her bedside table, Becoming by Michelle Obama. I asked about her favorite anecdotes from the book and noted the muscles in her face relax during the conversation.

Over the next couple of days, as her diagnostic workup continued, we continued to build our relationship. With no test results to give her, my updates became friendly check-ins. She told me about her career in public relations, her family, and her dog. She asked about the challenges of medical school and what I liked to do for fun. In these moments, I realized that although I did not physically improve her condition, shared listening and presence were undeniably therapeutic.

Be your patient’s person. In the afternoons, when you have written your notes and are waiting for sign out, share your compassionate presence. Listen to the stories, hopes, and fears of those you are caring for. Know that in this way you are providing treatment for your patient’s soul. For the past two years you have been memorizing thousands of medical facts to care for your patients. Now is your opportunity to provide whole-person care by integrating that medical knowledge with your ability and desire to care for your fellow human being.

Over the course of the year, you will gain considerable skill in physical exams, patient presentations, and documentation. Compassion is a powerful tool you will develop this year but have been practicing your whole life. Utilize it.

Best,

Joe Fuchs

Dear Rising Third Year,

No one can tell you what's going to happen. No one can predict how you're going to feel, respond to, or handle what's going to happen. It's like going through a relationship for the first time. You're going to get all of this advice that you think might sound okay, but that you'll end up ignoring completely. Because everything you really need to know can only be learned through experience. Some of the advice people will tell you will be helpful, and a lot of it won't. Those around you aren't going to understand exactly what it is you will go through. Every single third year student has their own unique experience. It's just another example of how it is usually more harmful than useful to compare yourself to others. People might question your reasons for going through this kind of hardship; they might point out all of the difficulty of what you're doing. They will likely focus on how it negatively impacts you. But they don't see or feel what you see or feel, and you will be what you've always wanted to have a shot at doing. If there's one piece of advice that I want to give anyone going into their third year of medical school, starting rotations, and entering the life of a hospital physician, it's that now you should consider yourself at ground zero. There's no negative here; you can't get lower on the totem pole. You can't have people expect anything less of you than where you are right now. And you might hear that and think negatively of that kind of perspective. But in actuality, it's a superpower. Anything you do, anything you ask, will be a step above ground zero. Now is the time to make sure that your foundations are fully fleshed out, that the fundamentals are your strongest aspect. No one expects or even wants your specialization, they want a reliable, focused, cooperative, capable student, and most importantly, a student that learns quickly and takes feedback seriously.

You're going to enter into your first rotation feeling lost, unable to help. You might feel scared. And that is good, it means you have humility, and that you don't take what you are embarking upon too lightly. You have to push through that fear in order to ask questions. And you're going to say that you don't even know what questions to ask. That's okay. So, then your first question should be: what questions should I ask? And right there you've already started your third year.

Best,

Kasey Pickard

To the Rising Third-Year Student, Third year is not about your grades. It’s not about being a good student. It’s not about being impressive to residents or attendings, passing your shelf exams, or receiving good evaluations. It isn’t a tally of honors or high passes, passes or fails. You will consistently be told otherwise – sometimes explicitly, sometimes implicitly. Every presentation you give, every time you return home from a long day in clinic and hear a nagging voice in your mind that you need to study, every eyeroll from a resident or peer, every ICC career advising session will make you feel like third year is about your success. But it’s not.

The first time I remember feeling overwhelmed with the pressure to perform as a third-year student was during my first oral presentation on internal medicine. I remember grappling with the complex story of my patient’s presentation, how to integrate his many problems into a seamless story that made sense to my team. What I missed, at least initially, was the way that his many problems and unique history were starting to paint a picture of a rare hematologic malignancy that we had no idea was brewing deep within his bone marrow. Five days later, I became the person to share this information with him and his family, and with the help of the oncology fellow, I was part of describing a future he had never been expecting. I still talk to him and his wife, and they keep me apprised on his chemotherapy. Despite the rarity of his diagnosis and the poor prognosis, he seems to be doing well.

Five days after meeting that first patient, I was tasked with taking care of another patient navigating the initial stages of a cancer diagnosis that would drastically alter his and his family’s lives. He was a 63-year-old man who had been diagnosed just a week prior with metastatic esophageal carcinoma despite having no risk factors. I would eventually attend sixteen of his appointments, collaborating and *occasionally* arguing with many attendings at Denver Health until I helped him obtain the necessary diagnostics and treatments for his disease. I was present for his final appointment with palliative care during which he decided to transition to hospice, and I was able to say a heartfelt “see you later” to him then. I was so moved and devastated by this final meeting that I saw myself flounder in the remaining clinics that week: I gave a few poor patient presentations, forgot to follow-up on a few lab results, and generally, felt myself navigating the hospital setting in a daze. It took me a lot of time over winter break to stomach the loss. He passed away in January.

These patients are just two who impacted me on my journey in third year, just two of many who taught me that my role in their care was actually invaluable. You will have your own list of patients who will tremendously impact you. You will walk out of third year as a changed person. You will discover a vision of the provider you hope to become, and your vision will be formed by countless interactions with patients who truly and genuinely need your care.

That’s the thing about this year. For many of us, our whole lives were about achieving the goal of becoming a medical student; it’s our identity. It won’t be long into your third year when that identity will start to crack, and I encourage you to let it. You can make this year about continuing to seek the highest honors in everything you do – you are an achiever after all, or you wouldn’t be here – but I encourage you to look at your time in clinical rotations as an opportunity to leave that identity behind. Third year is about your patients, but it’s also about you – about figuring out what kind of person and provider you want to be as you stand alongside human beings as they navigate some of the best and many of the worst moments of their lives. So, when you feel the pressure mounting to impress one more attending, submit

one more research proposal, perfect one more oral presentation, I implore you to take a moment to stop and remember this little piece of advice:

Third year is not about your grades.

With care,

Kira Grush

Dear Phase III Student, You are about to embark upon what may be the most transformative leg on your journey to becoming a physician. This is an anxious time for many in your position, but you should rest assured that the odds are in your favor. There are many along the way who are working to help you succeed, and you are going to come out of this year stronger, smarter, and wiser than you are today. In that spirit, I’d like to share some things I wish I had been told when I was standing in your shoes not so long ago.

1. It’s okay to be wrong. This is how you grow, and how you demonstrate that growth to your team. Your residents and attendings are going to probe you to determine the boundaries of your knowledge and then push you to surpass those boundaries. Remember that nobody expects you to know everything—people understand that you’re there to learn—and remember that there are multiple layers of supervision between you and the patient. Put forth your best effort, honestly and confidently, and then learn from the mistakes you make.

2. Your value is not determined by evaluations of your performance. There will be times when you put a ton of effort into something, only to receive lukewarm feedback or to have your extra effort go unnoticed. Evaluations in the third year are incredibly subjective, and at times, this can be really frustrating. Resist the temptation to take feedback personally or to become discouraged. Remember to be kind to yourself. Remember that the people you work with are there to help you learn and be successful.

3. Do not ever lie. Ever. Your integrity and credibility may be the most valuable contribution you bring to your team. It’s always better to admit that you didn’t think to ask the patient a specific question or that you didn’t have time to perform a specific part of the physical exam than it is to make up an answer and hope that you were correct.

4. Be engaged, even if you’re not interested in the specialty as a career. Nobody likes to teach somebody who isn’t interested in learning. The rotation may be your last opportunity to learn about and experience that area of medicine, and you should strive to make the most out of that opportunity. At the very least, you’ll have a better experience, and you might even find yourself enjoying a specialty that you hadn’t previously considered.

Congratulations on making it to this point in your training! The next year will no doubt be fraught with challenges. You’re going to be tired. You’re going to study harder and longer than you anticipated. You often will not know the answers to questions that are asked of you. And there may be times when you doubt yourself and your decision to pursue a career in medicine. But you’re also bound to meet people who inspire you, and bound to see and do things that fuel the passions that first attracted you to this profession. Work hard, learn lots, and embrace this adventure!

Sincerely, Matt Minturn Class of 2019

-Read p26 by Matt Minturn

Dear Phase III Student, You may have heard that a great deal of phase III grading is much more subjective than what you were accustomed to in the past. Expectations of you now not only demand that you demonstrate what you know, but also who you are as a person and how you present yourself to both patients and preceptors. Throughout third year you will constantly be thinking about what your role should be while on service. You will worry about whether your attendings and residents like you. After rounds you will ruminate over how you were corrected mid- presentation by your attending in front of your patient. You will stress about where you should be standing in the OR, so that you can get the best view of the procedure while not overcrowding and annoying the chief resident. I think that you will find that these thoughts are mentally draining and counterproductive to your growth in the clinical space. But we cannot help it! We are social creatures and care about what others think about us! Not to mention that at the end of the day, the people we want to impress are grading us! Rest assured that these thoughts are normal. Once you enter the clinical space, it is easy to forget that you are still a student and not a resident or an attending. Your responsibilities are different: you are here to learn, you are here to make mistakes, you are here to explore the kind of doctor that you want to become. It was not until I was half-way through my third year that I realized that my most important role on the team is that of the student. Although it may not feel like it, as students we do bring value to the team. So, remember that you are here to learn, so be curious! Ask questions! Take on patients that will challenge what you know and that will force you to learn. Put yourself out there, speak up, and do not be afraid to be wrong! Attendings and residents know that you are here to learn and for the most part, remember what it is like to be in your shoes. They know that you do not know everything, so do not try to fool them into thinking that you do- be honest. Third year is when you will begin to feel like a doctor. It will happen little by little. But by the end of your third year, I guarantee that you will be impressed by how far you have come.

Best wishes,

Gabriel Yepes

To Hold a Clamp

Dear Outstanding, Intelligent, Hard-working Third year, Stepping into the world of full-time, immersive clinical learning is amazing. It is freeing. It is finally getting to do what you’ve wanted to do since you first decided to pursue a life in medicine. For me though, as the months wore on, a bit of disillusionment crept into my view and largely took the form of feeling as though I were a liability to the team. My presentations were long. I always forgot something in my exam or history. I pestered the residents with questions. It seemed like whatever information I provided was already known and that the numerous plans I suggested were turned down. In a sense, sometimes I felt like I was going through the motions, not really a meaningful part of the team. That is until one day during a two-week rotation on the cardiothoracic surgery service. I would like to share this experience with you. “Mike, get over here and hold these clamps!” “Hold tension exactly like this.” “Do not move at all unless I say to.” These three rapid fire commands rammed themselves into my consciousness and animated my otherwise still body as I observed not only one of the most intense surgeries of my rotation, but also one of the most intense experiences of my life. Before my eyes, contrasting sharply with a field of sterile blue, was a pool of bright red, with silver tools and gloved fingers and suction tubes darting about like frantic fish in a bloody lake. This way and that, each new geyser of red announced a new tear that filled the chest cavity with only more red. The cardiothoracic surgeons decided to remove a large, well- vascularized tumor that had wrapped around and invaded the innominate and right subclavian arteries. But the extent of the invasion was only truly made apparent when blood began pouring into the chest cavity. Each new attempt to stop the bleeding led to a new tear as friable tissue yielded easily to the tension applied. The attending, issuing commands intermingled with curses, was at times suturing vessels at the bottom of the pool; his visualization was largely obscured. Massive transfusion activation was called, and the patient received over 15 liters. Blood entered the body only to be dumped out into the cavity and then suctioned up out of the body again. The brief moments when suctioning proved adequate revealed mangled flesh foreign to any depiction in a Netter atlas. And in the midst of this…I heard my name called. Medicine defined by an endless succession of Uworld questions or CAPE sessions or small group meetings or IPED lectures evaporated in an instant, and reality hit me across the face. That perpetual, gnawing sense that seems so inherent to the MS3 psyche of being a liability, of being in the way, of my thoughts, words, or actions being merely an academic exercise rather than a meaningful contribution to the team, evaporated. Superficiality had been suctioned away with the first 4L of blood. Here in this moment, every action engendered an immediate consequence, each decision could not be undone, every team member was needed. There was no more going through the motions; each motion was real, impactful. I held three clamps in one hand, forced to twist my fingers in ways they had never been. I held tension in the way the attending demanded and elevated the three vessels dumping blood into the surgical field so they could be viewed, allowing him to suture them closed. And I held my breath, silently praying, determined that no matter the cramps or how tired my arm or hand became, I was not going to let the patient or the team down. For the first time I really felt needed. Finally, with the bleeding under control, the attending simply said, “Okay, you can let go now.” I relinquished my grip and breathed a sigh of relief under my mask. As I returned to my place at the student’s spot by the operating table, the attending turned and said “Hey, you did a good job. Thanks.” And we started closing the patient up.

The role of the third-year student is not the most glamorous, and it will be fraught with feelings of inadequacy, getting in the way, going through the motions, etc. But you really are an important part of the medical team. Your questions and the opportunities to teach you will make the team better. You can dedicate more time to each patient and learn the details of the story that the team will not necessarily be able to learn. There are the multitude of little, thankless tasks that you can perform that helps the team to run smoothly. And there are those occasions when you are the last available set of hands, and you are needed to hold the clamp. So, do not get discouraged, just find ways each day to help the team and to care for your patients.

Michael Klausner

Dear Phase III Student, Welcome to the best (and worst) time of medical school. Say goodbye to the days of sitting in a classroom, and hello to actually getting to interact with patients. During this year, you will grow and change in ways unimaginable but come out the other end a more fully formed clinician. To do that, I give you the following advice: Be open minded. Try on the different “hats” that is each specialty and imagine if you could see yourself doing it for the rest of your life. I wore the Emergency Medicine hat for the first two years of medical school, replaced it with Surgery for a couple months, and ultimately decided the Psychiatry hat fit best. If you had asked me what I was going to be, Psychiatry wasn’t even on my radar. But that’s the beauty of third year: you get to find what you love and start to believe you were meant to be here. Play the game but stay true to yourself. You will often hear that “third year is a game, and you just got to play it.” You must be enthusiastic but not too enthusiastic. You must be eager but not too eager. Evaluations are subjective but are also the most important factor to your overall grade. Unfortunately, there is no way to do well in third year without “playing the game,” but that doesn’t mean you need to change yourself. I was told during my internal medicine rotation that I needed to be more bubbly and smile more when talking with patients. I did not feel comfortable doing this as it just isn’t who I am but instead tried to compensate in other ways – I took on more patients, got to know my patients better than anyone else – and showed that my relationships with my patients depended not on my superficial personality but on who I was at my core. Do not compare yourself to other students. This is something I had to remind myself of daily. For some of your rotations, especially Surgery and Internal Medicine, you will have another third-year student with you. It is easy to compare yourself and become competitive, with each of you trying to be the better medical student. My advice: just don’t go there. Instead, confide in that student. Befriend that student, even if you never talked before. Complain with that student, not about that student. These rotations are hard and exhausting, so it’s nice to have someone there going through the same thing as you are. Ask for feedback constantly. One of the best things you can do in third year is ask for feedback – from your residents, attendings – and then practice it. Sometimes it will be vague, but other times you will get feedback that is actually helpful. Taking the time to practice the feedback not only helps you figure out your own style but also shows you are able to take constructive feedback and work on becoming a better physician. Be honest about what specialty you are thinking about going into, even if it isn’t the specialty you are rotating on. There are those that are genuinely interested in the specialty and say so, but there are also those that aren’t interested in specialty but say they are. People can easily see through this façade, and ultimately, it will look insincere, unless you are a fantastic actor. People ask you what you are interested in not in the hopes that it’s whatever they specialize in but to better understand you and to tailor what they teach you to better fit your desired specialty. Third year is a rollercoaster, all you can really do is jump on and enjoy the ride.

Sincerely,

Erin Sturman

Dear Third-Year Student, I’m not a vocal individual, nor am I one to share my sentiments with those outside of a few close companions who have proven they can endure the aimless ramblings of a boy with a couple too many thoughts and a bit too little experience. Surely, none of the things I say here will be profound or novel, but I assure you they are genuine. When thinking about drafting this letter, I thought it would be nice to keep it simple, concise, and organized, but the truth is that third year is none of those things. That leaves you with an assortment of thoughts: some of which may inspire, and most of which will fall flat. Here are mine, in no particular order: • Third year is not an epiphany. Don’t expect to have watched a code, a fetal demise, or the tears of a parent as they say goodbye to their child and emerge on the other side as a changed human. This, like all things, takes time. Slowly, your perceptions about the human experience will shift, as will your ability to connect with others through their suffering. • Avoid asking what your responsibility to your patient is, and instead ask what you can do for your patient. The difference is subtle but important. Our healthcare system is fragmented and fraught with deferment. Take pride in your ability to make tangible changes in the lives of your patients and actively seek out opportunities to do so. Often, you are one of a very few people who is advocating on their behalf. • Stand up for yourself. Recognize that any attempt by a senior member of the team aimed at making you feel inferior is a reflection on that person and a fragile ego rather than an inherent fault of your own. • Don’t get bogged down in what you don’t know. Medicine is not about what you know today, but what you will know tomorrow. • Take note of the injustices you witness and internalize what they signify. The questions you ask may very well be the basis for future work in pursuit of making our world a more equitable place to live. • Never cease to appreciate the privilege it is to be invited into the lives of your patients. Recognize the role you play, even now, in defining some of the formative experiences of their lifetime. • Don’t sell yourself short. While today you might see yourself as “just a third-year med student” and will question whether your thoughts count for anything at all, soon you will recognize that those thoughts were not simply the ponderings of an uninformed and inexperienced clinician, but those of a thoughtful and conscientious human. • Say goodbye to your patients every day. Remind yourself of why you do this work. Understand that you have the luxury of leaving the hospital each night and that your patients might not. Recognize that your face may be one of the only constants and sources of joy they experience during their hospitalization. Embrace that responsibility and take pride in the fact that you might have such a positive influence in someone’s life.

Connor Fling

Dear Phase III Student, I’ve figured out the ultimate key to having a successful third year: Empathy.

Wait! Don’t roll your eyes and turn the page just yet. I have a different spin on it for you, I promise.

I bring up empathy not to remind you that it is what will allow you to help others (but that is also important….yes, yes, of course), but to help you see that empathy is also what will allow you to help yourself during third year (and yes, by “helping yourself,” I mean getting better clinical grades).

Empathy describes one’s ability to understand the feelings and perspectives of others. We talk about doing this with patients all the time, and that will undoubtedly help you do better in third year (and be a better doctor, person, etc).

The real secret to third year success though is knowing how to empathize with your residents (or anyone else who is evaluating your clinical performance for that matter).

Don’t get me wrong; you do need to know things! But understanding what your residents are going through will help you to figure out when it is actually the right time to mention those things that you know. It will allow you get a feel for how much you should advocate for yourself, and maybe when you should back off for a bit. Was your resident scolded by another member of the care team today? Is it still early fall and your intern is feeling inadequate? Does your third-year resident worry they won’t practice medicine safely next year when they’re an attending? Great! Use this information to guide your interactions with them.

Putting yourself in your residents’ shoes will also allow you to better understand what they think makes a “good” medical student. There will be expectations they give you at the beginning of your rotation, but a lot of it will be hidden. It’s up to you to try different things out and see to what they respond favorably. They may not always be direct with their feedback, so pick up on their nonverbal cues to obtain your most honest answer.

I worry this letter will be interpreted as how to play “the game.” Sure, one can look at it that way. I will also say that I left third year not only with tons of knowledge gained, but also with meaningful and lasting relationships with residents who made me feel valued. You are not going to get check-in texts, bar hang invites, career guidance (and yes, good evaluations too), unless you use your empathy and interpersonal skills to build the foundation of those relationships. Being more aware of what your residents are going through now may also prepare you for your own time during residency. It will be here sooner than you think!

Anonymous

Dear Phase III Student, First of all, CONGRATULATIONS! You have worked incredibly hard, and I’m so proud of you! You’re now done with the “worst” half of medical school, given that you are likely here to become a physician and work with patients- not to ONLY STUDY! Although, spoiler alert, 3rd year still involves studying – sorry guys. Yet now, you finally get to do what you studied vigorously for: to BE a doctor. Well, a doctor with “training wheels,” but you are now one step closer to achieving your dream.

I am so excited for the growth that you will experience in 3rd year. Growth that, at times, will feel like a gentle stretch and at other times, will feel like you are being pulled as taut as the bowstring of a long bow. Now, I don’t say that to scare you, just to be real with you that 3rd year will stretch you in ways you can’t even imagine – but that is just part of your growth towards becoming a physician. That being said, there ARE ways, to help make that stretch a “little bit” more comfortable. I now offer you MY “rules” to hopefully help you throughout your 3rd year, especially during those “taut like a long bow bowstring” times.

So, here are my 5 Zombieland-esque “rules” to survive 3rd year:

1. Be kind to yourself. This may seem obvious, but there are going to be times that you will make a mistake (you ARE a student). As medical students, we do NOT like making mistakes. However, I hope that when you make a mistake and your first instinct is to start the old song and dance of mental beratement, you remember to be kind to yourself. Be kind because not only do you DESERVE kindness, you are also SUPPOSED to make mistakes given that you are a learner. If you knew everything already, then wouldn’t you be the resident or attending? This may seem silly to point out, but honestly, it’s probably the easiest of these “rules” to forget.

2. Take care of yourself. Being kind to yourself also means taking care of YOU. At times, 3rd year is very taxing, and thus it’s SO important to take breaks when you can and keep up with any activities that help promote YOUR wellness – whatever those are! Me? I finished waaaaay too many Netflix shows. Others have gone skiing, run marathons, visited family, and more, even during 3rd year. You can do the things you love; you just won’t be able to do them AS often. Ultimately, as the saying goes, “you can’t pour into other people’s cups if yours is empty,” or something like that. So, do your best to take care of yourself so that you can take the best care of your patients!

3. Be a team player. Be willing at times to do some “grunt work”. Yes, it’s not your job, but it WILL be. In reality, a lot of medicine involves grunt work. Grunt work meaning – calling doctor’s offices, faxing and making copies, or running back down to the conference room to grab the coffee your intern forgot. These may seem “unimportant,” but they definitely aren’t “unimportant” to your team. Think about it. If you call that doctor’s office for your interns, they are now able to get orders in, write their notes, and get home earlier! I can GUARANTEE that your team members will appreciate you so much more (and grade you so much better) if you are willing to help your team in these “unimportant” ways. Remember: Medicine is a TEAM sport!

4. Use your 3rd year medical student status to your advantage. There may be times that you feel like a “burden” because you aren’t able to do everything the doctors can. In

these moments, I encourage you to take a breath – breathing is good – and think about ways that YOU, the little 3rd year medical student, can make a difference. Don’t believe me? The next time you’re in a code or stroke alert, look around. Is anyone talking to the family? If the answer is no, go support them! You know enough to explain what’s going on, offer reassurance, and answer some questions. The doctors can’t help the family – they’re caring for the patient – but YOU can. Thus, in those moments when you feel that you’re “just in the way,” look around. Is there someone you could help? Is there something you could do? I bet there IS something only YOU can do. It’s just that you didn’t see it because you weren’t LOOKING for it.

5. Remember that you are NOT alone. Not only are all your classmates going through it WITH you, many have gone through it BEFORE you: attendings, residents, interns, even MS4s. They’ve done it too. So, during those times when you feel alone, when you feel that you are the only one messing up – reach out. Reach out to your advisors. Your mentors. Ask them how they felt during 3rd year. Ask them if they ever messed up: I guarantee they did, and their “mess ups” are probably more embarrassing than yours! Ask them how they got through it, and then ask them to help YOU through it. Asking for help is a strength – not a weakness. Admitting you can’t do it all alone takes a LOT of courage, and I enCOURAGE you to take that leap of faith. I guarantee you will become stronger because of it.

There you have it. These are the “rules” that I wish someone would’ve told ME when I was about to start 3rd year. However, even with these “rules,” know that your 3rd year experience will be unique to you. It’s an individual journey that will stretch you, causing you to grow not only as a medical provider but as a person! Ultimately, I am excited for you all, and I cannot wait to see what kind of doctors you will become! See you all on the wards!

Sincerely,

Megan Brown

6AM C-Section A mix of anger and enthusiasm How can this be so common? My brain drifting off, wanting to see my bed before me The fresh, flowery morning earth The aroma of sizzling breakfast Guilt free sleep during daytime The excitement of the coming night, the gravity of the coming night

Matthew Masur

Dear Rising MS3, Congratulations! You made it to third year! Everyone (MS4s, residents, fellows, attendings, etc.) in the clinics, wards, EDs, and ORs is stoked for you to be here. Trust me. And while we can wax on and on about how amazing third year is, I think it might be more useful to share some tips for your awesome journey ahead.

Life Tips • You are a human being! You can’t take care of others well if you don’t take care of yourself first. • Eat food, bring snacks (good for your white coat pockets), drink lots of water. • Find the bathroom on the first day of a rotation; it’s also OK to use the bathroom during rounds. No one will care. • Take some time to enjoy the sunrise/sunset when you’re arriving early/leaving late. • It’s OK to accept whatever you’re feeling. Nervous, excited, scared, passionate, tired, joyful, discouraged, proud. Third year is a roller coaster of emotions; all are 100% valid. • Lean on friends, share your struggles with peers, and help each other out. We’re all working towards the same goal!

Practical Tips • You are an important asset on your team, and they want/need you there! • But…when a resident tells you to go home, you GO HOME. No need to ask, “Are you sure?” You’ll be on service for long hours later in your career anyway. I promise going home a couple hours early won’t be detrimental to your education. • Become best friends with the interns and MS4s on your team. You can practice your presentations with them, ask questions, learn the EMR, etc. • Pro tip: studying about your patients’ conditions = studying for your shelf and Step 2. You’ll be improving your patient care AND your scores! • Use that student card as often as possible (i.e. “Just for my learning…”) • Download UpToDate, Doximity, and MD Calc on your phone. These will be your best resources! (NOTE: you can mask your caller ID and fax from the Doximity app) • Presentation style differs by rotation and by attending. It never hurts to ask the residents or even the attendings what they prefer! • Want to impress your attendings? Look up some primary literature related to your patient’s case and present something like, “According to the RECOVERY trial… so my plan is …”. They’ll dig it, and you’ll help educate others on your team too. • It’s OK to not know answers to “pimping” questions. Either give your best educated guess or say, “I don’t know, but I can look it up and give a quick chalk talk tomorrow!” • Know your patients’ data, but if you forget to look something up, just say so. It’s much better than making something up, and it builds your team’s trust too! • Listen to all the staff around you: nurses, MAs, CNAs, RTs, custodians, etc. Chances are they can teach you something that will improve your patient care.

Patient Tips • Patients are human beings too! Empower them as such by taking the time to ask about how they’ve been with their spouse for 50+ years, their experience serving in the military, their career as an artist, their hopes and fears etc.

• Go the extra mile for your patients. Know they have an upcoming surgery? Go check on them post-op. Know they have a CT scheduled? Call down to radiology to check when they will go. Know they should be getting Lasix for net negative 1-2L? Check in with their nurse to make sure the meds are administered. YOU are your patient’s provider, so advocate for them to the best of your ability. • When the medicines/surgeries don’t work, you can still be a healing presence in your patients’ lives. It all comes back to human relationship. • Say goodbye to patients before you leave a service. They will appreciate it. Also cherish the many “Thank yous” you will receive. These will be your light on the darkest of days.

Lastly, continue to cultivate your own relationships. Welcome uncertainty. Embrace vulnerability. Be kind and curious. Have fun. Stay human.

Welcome to the next phase of our incredible profession! You are meant to be here.

Andrew Pham, MS4

Dear Third-Year Medical Student, Congratulations! You have made it to the coveted year of medical school, the year you can really apply what you studied as you sat in the library or coffee shop or at home for the last 2 years. You’ll really learn it now. There’s nothing like seeing a patient with a certain condition, empathizing with the impact on their wellbeing, their life, and getting to know their story and their family that will stay with you forever. You’ll see standard medicine cases and those things that you thought you’d never see but become common to you. You’ll see your good share of head-scratching, intriguing presentations and even more fascinating, inspiring people.

There will certainly be ups and downs. My first patient deaths hit me hard, even if I was not physically present for the death. You may cry as you drive home as you reflect on the patient and how the family will do. You may listen intently as a family gathers in hospice reflecting on their loved one and cry with them without shame though you just heard their story only a couple hours ago and just met them 15 minutes ago.

On the flip side, you may celebrate the birth of a baby, an exciting discharge from the hospital after a complicated months-long hospital course. I’ve found the most satisfying of everything is helping patients and families on their journeys of health, being an advocate for them, helping them learn about a particular illness and condition, and hearing the words, “thank you, you did such a good job caring for my child/family member/friend and answering my questions. I truly appreciate you.” It’s times like these that remind me it is an absolute privilege to work in medicine- to be a partner for patients and families, to help them in a time of great need. These times certainly balance the fatigue and burnout that may come with the 17th or 27th hour of work or walking out of a room overwhelmed by a patient’s situation.

Now, remember, though 3rd year can be a lot of work, remember to take care of yourself. Maintain your exercise routine, sleep, and eat healthy. Those can be easy to say and hard to do but trust me they make a difference.

Best of luck, MS3s! I know you’re going to do wonderfully out there!

Best,

Megan Kunkel GHHS

Dear Phase III student, Until now, you’ve learned about the scientific principles of medicine, memorized drug mechanism of action, and spent afternoons with simulated patients reviewing how to hold a stethoscope and express empathy. I want you to know that those are all real things and that you’ll continue to recite and perform them in Phase III. In fact, you’ll become much better at all of them. Your improvement will be exponential, and you won’t appreciate your progress until you take your first break. This is all wonderful, but I wanted to tell you about the aspect you couldn’t learn in your first two years: the business of medicine. Not that I fully understand it right now either, but I think you’re owed a heads up. You’ll see the hierarchy in hospitals for the first time: teaching and nonteaching attendings, the workhours of residents, and the amount of paperwork checklist that have to be completed for billing. All of this will impact how you view medicine and influence your career choice. I write this to tell you that at times this is the part that is overwhelming and that you’re not alone in these experiences even though you’re the only medical student on your team. Your peers and upperclassmen have had the same feelings, and you’ll find strength and motivation in sharing those feelings with others. I want you to know that in hindsight Phase III is an incredible year of personal growth, but that in the moment, can be a real pain.

Richard Smith

Dear Phase III Student, It’s okay to cry. If I had a dollar for every tear that I shed in third year, I could afford to pay tuition. It’s okay. Your emotions will come at you like the Colorado weather: unexpected, unpredictable, and with a wide variety. Some tears will be happy ones like at the successful end of a delivery. It was during one of my overnight labor and delivery shifts, only the third all-nighter that I had ever pulled in my entire life. I remember the tension in the air as more and more providers filled the room, until the attending asked everyone to move aside and quickly consented the patient to an operative vaginal delivery. I remember the stillness when no one seemed to breathe, or even move, as the forceps were brought in. Seconds later, I cried watching the new mom cuddle her tiny baby boy on her chest.

To be completely honest, I’ve cried in many places. Mostly at final salutes at the VA. It’s okay to cry. Even the hospital chaplains and the VA police are not dry-eyed. If you are rotating at the VA, you should attend a final salute. It is a ceremony to acknowledge the passing of a veteran and to honor the sacrifice and service to our country. The late veteran passes through the halls of the VA draped in an American flag quilt as the final taps are played, followed by the family, led by the VA police, and supported by staff lined up on the walls. My very first patient on my hospital service died unexpectedly, and I cried the big ugly tears as his family thanked me for taking care of him. It’s okay. It hurt less to cry once I accepted that I could. And you can.

There are a lot of things that you can do, my Phase III friend. You can do a history; you can do a physical exam. I promise you can do wonderful things during your rotations. You can be the friendly face for a scared hospitalized child. You can be the advocate for your patient when talking to your team, making your patient’s concerns known. You can be the first to show an expectant mother the heartbeat of the fetus. You can reach inside someone and feel the biceps tendon, the gallbladder, and maybe even the heart. You will be challenged by Phase III, and I know that you will all rise to the occasion. Just remember that it is okay to cry. The emotions that we feel do not separate us from the task at hand, rather I believe that they connect us to our purpose as providers to recognize and care for those in need.

I believe in you, Phase III friend, even if at times you don’t even believe in yourself. Don’t be afraid to cry, and don’t be afraid to be the wonderful, talented, compassionate providers whom you have worked so hard to become.

Sara Delenn Graves Pronouns: “she, her, hers" MD Candidate | Class of 2021 University of Colorado School of Medicine [email protected] (650) 504-4890 c (call/text ok)

Dear New Phase Three Student, Whether you are filled with excitement or anxiety or both, this is the start of a whole new adventure and a whole new way of learning. More than ever before, this year you must remember that you are NOT a brain on a stick.

You never have been just a brain on a stick, although you may have gotten the impression over the past couple of years that you are… when we are only given feedback about the facts we are learning and how we are performing intellectually, it is impossibly tempting not to lean into that evaluation-mindset and find your purpose, affirmation and motivation within the short-lived thrill of receiving stellar grades and outstanding test scores.

No longer.

You will now have the opportunity to learn by stepping into patients’ lives in ways you never imagined. You will sit in quiet hospital rooms with dying old men. You will sit in awkward silence with teenage girls, teetering on the brink of trusting you with deep, dark secrets. You will be the first hands on a new, blue, gasping human. You will see life, death, tears, laughter and pain in ways you never have experienced. Those humans you will touch do not care what you know.

They don’t care about your Step scores, grades or the time you spend studying for your shelf exam after you leave their bedside. They care about the way you talk to them, the way you care for them, how much you look them in the eyes, how much time you take listening to them and explaining things to them. They care about how you make them feel.

You are not a brain on a stick. You are a spiritual, connected, caring, thoughtful and sensitive human. This year, you will learn that that connection can be both an incredible gift and an acutely painful burden. You will try intellectually to make sense of what you see. It is my hope that in those moments, when you search desperately for logical answers, that you pause and allow yourself to feel. Allow yourself to ask the difficult questions. Not just difficult questions regarding evidence-based treatments or adverse side effects, but the difficult questions of yourself. Allow your heart to learn about itself and allow your soul to engage with the learning, also. You will grow more than intellectually this year if you bring your whole self to these inquiries.

You are not a brain on a stick. You are a physical body. One that needs water sometimes… not just coffee. You need to stretch, eat vegetables, sleep, exercise, breathe deeply, cry. You will get weak when you’re in a hot OR retracting for hours on end. You will feel sick to your stomach at the sight of certain wounds, blood, pus or at the smell of C. Diff, chorioamnionitis, or diabetic ulcers. Your body is your friend… not something that is hindering you from honoring because it passed out, threw up or got the flu. You are more than just your intellect.

You will, this year, stifle back tears. You will convince yourself it is a matter of professionalism to do so. You will struggle for composure, fight back frustration and come to terms with the anger at the injustice and pain you see. Do not smother and suffocate these difficult feelings. Do not lock them away and bury them deeply- only to allow them to be further buried and forgotten… but never really gone. Have the courage to face them. Ask the physicians you work with how they face them. Feel them. Write about them. Talk to mentors about them. Find people who see your pain and can tell you about their own.

Healing- true healing requires relationship. You will be a better doctor when you see your patients, hear their stories, meet their children and stay next to them when they cry. You will be their doctor when you are more than just intellect. You will be there accompanying them through these most difficult, painful and joyous experiences life has to offer. You will be there. You will be present. I’m already proud of you.

With admiration & a bit of jealousy,

Amanda Tompkins GHHS

Dear Phase III Student, This year ahead will change you and transform you very realistically into the doctor you have worked so hard to become. It is thrilling and exhausting and inspiring and profound and likely just about every other emotion out there! I hope to offer you one insight for success and one simple story. My first recommendation relates to clinical knowledge. There is always more to study which truthfully is overwhelming. I have felt many times that I am behind, that I know less than what I should or at least less than my classmates. I encourage you to fight this feeling, to be confident in the work you have done to be here, to trust that you are learning and growing. Don’t focus on how high or how low your step 1 score was. State what you know with confidence, even if you are not 100% sure yet. Support this by establishing a steady learning pattern that works for you during the first block because this studying is different from pre- clinicals. You already made it this far; all of you are set up for success! My second thought is a story that I know you will experience in your own way. We have the absolute privilege to start caring for real people. We can make a difference for them even now: seek out those opportunities and serve every patient with all of your heart! I had the opportunity to share the hard news with a patient and her family that she needed surgery. This was unexpected for them and naturally left them feeling scared and guilty that they hadn’t come in sooner, but I was able to comfort them. After the experience, they stopped to tell me that I had made all of the difference in their care. They looked me straight in the eye and said that whatever I do as a physician, that I “should be the kind of doctor that communicates with patients often because that is (my) gift.” Your gifts will shine too, and your patients will be all the better for having you. I wish you the best of luck ahead. It is most certainly a lot of work, but it is worth every bit.

Sincerely,

Stefan Peterson

Dear Phase III Student, I hope you are doing well!

You are transitioning into an incredible time as you begin to apply your pre-clinical knowledge to actual patients. Without a doubt, third year of medical school is a mixed bag of emotions. You will experience the entire spectrum of emotions from pure elation to sorrow to anxiety to empowerment, and everything in between. While this will be the hardest year thus far, it will also be the best year of your medical training. This is why you came to medical school: to treat patients and make a difference in peoples' lives. As you read through these letters, you will acquire a vast amount of knowledge to help you succeed. So, I will leave you with these three tips from my reflection on third year.

First, before each rotation, take the time for prospection on what you would like to gain from each rotation. For those of you who are undecided on a specialty, this is a time to explore and immerse yourself in that field. For those of you who are set on a specialty, utilize each rotation as a means to talk about consultations and how that field relates to your specialty of choice. Regardless of which type of student you are, approach your third year with an open mind. For most of your rotations, this is the last time you are getting to practice that type of medicine, so soak up these experiences. You might just surprise yourself on what type of medicine you truly want to practice.

Second, be ready to jump in and be involved in patient care as much as possible. You will have an abundance of opportunities to gain additional skills during your third year. Take these opportunities to grow and expand as a competent provider for your future patients. Leave your fear at door and don't be afraid to make mistakes, but make sure you also have the proper supervision. You will make mistakes during this year, that is a given, but that is perfectly fine because you are learning and so is everybody else around you. If you make mistakes, that means you are putting yourself out there in an effort to expand your knowledge base. There will be days that you feel destroyed because you were off your game, but you are surrounded by your classmates who have been in the same place. Lean on your friends and families for support during this time. That being said, I believe that you will have significantly more good days than bad. You will get to exhibit your medical knowledge, and you may even think about things that escaped the minds of current providers.

Third, invest time to actually listen to your patients. I know this may seem obvious, but you will be extremely busy trying to meet the demands of your medical team and patients. Although, understand that each year you progress in training means increased responsibilities and decreased time that you can spend with patients. Take advantage of this opportunity by going to sit and talk with a patient if you are told to go home early. Going above and beyond to do this will help patients feel heard as they are stuck in the hospital and you can then use this information to provide more comprehensive care by making patient-centered medical decisions. You have the opportunity to heal patients and change the way they view the medical system. You are not a nonfactor during this year; you have the power to improve outcomes and make people healthier. The days will be long and hard; the nights will be filled with tasks and studying, but you will feel more fulfilled during this time than any other time in your medical training.

Enter into third year knowing that you can do this and that you will come out on the other side with a plethora of experience. You won’t realize how much you have grown over this year, but you will quickly adapt and transform into that physician whom you have envisioned.

Warm regards,

Dylan Rakowski

Dear Third-Year Student, These are my bullet points of tips/do and don’ts for each block of 3rd year. I hope they are useful- but if not, feel free to shred them with the PHI documents when you actually locate those bins!

Family Medicine: -Apparently Chacos constitute shoes so feel free to give your toes a little tan. -Know how to work with a paper chart even though they aren’t common. When the EMR goes down, you’ll know what to do! -If someone asks you to participate in a video for preceptors at CU about preceptorship that every single CU preceptor will see in the future, be prepared to be coached by Dr. Seymour. -Listen to each and every one of your patient’s complaints even if they don’t seem like they need to be addressed right at that minute. -Counsel patients who smoke about quitting; it’s always worth a try. -Befriend the office staff. They will often save your butt. -Don’t offer that you were a phlebotomist unless you are ready to draw some blood on patients whose veins hide before you sit them down.

Internal Medicine: -Every single thing in that little glorious book, Pocket Medicine, is fair game to be asked about anytime, anyplace! -Take ownership of your patients. You should be the first person they look at when you walk in with updates. You should always address their questions first; you might even have the opportunity to be the one to inform them of a new diagnosis or deliver difficult news. -Some attendings won’t give you the time of day. That’s okay, but make sure when there’s a little downtime you ask them some questions, so they remember that you are there to learn. -You will be asked many, many questions every single day. It’s okay to not know the answer but offer to look it up for the next day. Your attendings will really put you on the spot on this block. -Yes, those 20 problems on the list should be discussed one by one.

Surgery/ Anesthesia: -Hold those retractors nice and tight. Your sweaty palms won’t be a factor while you are double gloved. -Observe your residents and attendings habits in the OR, and try to learn the steps of the procedure, so that you can anticipate. -When your attending asks you to step up to the head of the bed and replace the resident, don’t hesitate because you just might get to do the last step of a thyroidectomy. You might also close while your attending assists you and asks pathophysiology of PTH- yes, the kidney part included. -Offer to intubate as many patients as you can, but before that, make sure you know how to assemble the laryngoscope. Use both the Miller and the Mac. -Don’t be fooled by the curtain. Anesthesia knows an incredible amount of information about each surgery/ procedure, and they will gladly explain just about anything if you ask!

MSK: -If you are handed the power tools, use them exactly as instructed. -Work out before this block, especially if you’ll be carrying a leg or retracting for a joint replacement, otherwise your attending will say “You can do it!”

-Don’t forget your “helmet,” and more importantly, make sure the ventilation is working. -On that note, don’t forget your lead “dress” either. -Try to be the last one holding on to that hot joint cement; just don’t show your discomfort.

Emergency: -Anything could walk through that door at any time, so stay on your toes! -Don’t judge people based on your impression of them when they might be at their worst. -If you have to do a sensitive exam, take some time to get to know the patient first; they will feel much more comfortable that way. -Pull hard for those fracture reductions. -Make your sutures look as nice as possible. The patient will really appreciate it even if they aren’t quite with it at the time.

Psychiatry (emergency): -Give your patients space at all times. Both of you should be able to access the door easily. -Don’t be offended by the names you might be called. Many of these patients aren’t quite themselves when you meet them. -Advocate for your patients. After you’ve interviewed them for an hour, you’ll know them better than the rest of the team. -It’s okay to laugh with your attendings. If they didn’t find the humorous side to things sometimes, this job would be very hard. -You may very well spend half of your 12-hour shift trying to keep your cocaine intoxicated patient from leaving and having to calm him in Spanish. The nurses will appreciate your help. -Always interview minors by themselves and interview parents separately. This can often reveal a lot about a situation. -Remind your patients that SSRIs take a couple of months to start working, so they don’t go home expecting to feel better the next day.

Neurology: -Buy the darn reflex hammer and don’t use your stethoscope as a reflex hammer in front of the residents. -Practice localization and reading MRIs with the residents. It’s the only way to get better. -If you are at the VA, be prepared to call IT at least twice. -Always do a thorough neuro exam. The more you practice the easier it becomes to recognize what is abnormal. -Yes, you should use pins to test sensation. -Always have your resident check your ophthalmoscopic exam. You will not be a pro at this for quite some time.

Ob/Gyn: -When you are at your first delivery and all of the sudden your pant leg becomes very wet, focus on the soon to be mom, don’t make any faces, and don’t look at your pants. -The placenta is extremely warm and not the most inviting part of the delivery but deliver it with great care. -If you have a sensitive nose, this block is a little tough. -This is one of the times when you will actually sprint to places. -Always wear boot covers if you have time to put them on.

-During a C-section, take a split second to realize that not only are you one of the first people to see this little human, but you make very well get to stimulate them for the first time in their life! -Be prepared to manipulate the cervix for many of the gynecologic procedures. It sounds strange, but it’s very important so everyone can see what they are doing!

Pediatrics: -Take a moment to remind yourself that the dynamic with parents and guardians and your patient can be a challenging and very rewarding one. -These patients aren’t mini adults; they are incredibly smart and insightful, so try to address them in the same voice you’d use with most of your adult patients. -Sometimes they are scared, and they just want to be told what to expect. So, if something will hurt, it’s okay to tell them that and offer your support and a hand to squeeze. -Always try to be at eye level, especially with little ones. It makes a huge difference. -During the scary parts of an exam, it can help to sit next to your patient and let them listen to your heart or look into your eyes with the ophthalmoscope first.

Be yourself and show your patients you care about them and want to be there even if it’s not your favorite block! If you are lucky, you’ll have those patients that you will remember for the rest of your life and not just because they took your hands in theirs to tell you’d be a wonderful doctor one day!

Elia Rieder

AFTERWORD We are deeply grateful for all of the wonderful letters we received this year! The letters are a blend of practical advice, poetry and prose. Some are humorous and encouraging; others are cautionary and contemplative. These letters serve as an invaluable gift for our new third year students. We would like to thank all of the students who were willing to share their thoughts and experiences to support their younger peers navigate this challenging phase in becoming a physician. Thank you so much and best of luck in your careers!

Anjali Dhurandhar, MD Associate Professor of Medicine Arts and Humanities in Healthcare Program Center for Bioethics and Humanities

ACKNOWLEDGMENTS We would like to extend a heartfelt thanks to Dr. Amira Del Pino-Jones for her poignant and inspiring foreword. We are also grateful to Dr. Steve Lowenstein and the Gold Humanism Honor Society for their contribution to the publication. Specifically, we would like to thank Brenna Cameron, Yaa Asare, Gavriel Roda, and Amelia Davis for their creative and thoughtful foreword. Thank you to Hali Jenkins for helping with the cover design and to Max Osborne for his fantastic skills in photographing artwork. Most of all, we would like to thank all of the students for the generous gift of their letters!

SUBMISSION GUIDELINES We welcome submissions to the future edition of the Letters publication. There is no word limit, but we prefer submissions to be fewer than 1000 words and should not include identifiable patient information. We accept both poetry and prose, and you are strongly encouraged to be as creative as you dare. If you choose to submit your letter anonymously, stricter criteria for publication will be applied. Please submit your letter to Dr. Therese Jones ([email protected]) and Dr. Anjali Dhurandhar ([email protected]) for consideration for publication. The submission deadline is August 15, 2021. If accepted, your letter can be included on your curriculum vitae as a publication. We look forward to your letters!